TRICARE and ABA Therapy for Autism Ruling

On July 26h, 2012, a United States Federal Judge ordered TRICARE to begin paying for Applied Behavior Therapy (ABA) for dependents with autism. Active duty service members are able to receive services through TRICARE’s Extended Health Care Option (ECHO) program, which defined ABA therapy as a medical intervention. Retirees are unable to receive ECHO benefits.

Under TRICARE Basic, ABA therapy was defined as an educational intervention, not a medical intervention, making it ineligible for TRICARE coverage. ABA therapy, developed in the 1960s but only recently popularized in the late 1990s, provides intensive intervention using positive behavior reinforcement to teach appropriate behavior. Critics claim this therapy only promotes socially-appropriate response, not deeper understanding of behavior, and liken it to animal training. Proponents claim that once response is modified, understanding will come easier.

Kenneth and Dawn Berge brought suit against TRICARE and the Department of Defense in 2010. Kenneth Berge is an Air Force retiree whose son was diagnosed after the father’s retirement. In his ruling, Judge Reggie Walton called the current policy arbitrary and capricious. Under the ECHO program, active duty personnel may receive reimbursement up to $36,000 per year for ABA therapy treatment. In addition, the Federal Employee Health Benefits Plan, in which the Department of Defense participates with its civilian employees, also covers ABA therapy.

Things are far from settled. TRICARE refused to comment on the ruling, citing ongoing litigation, implying that they will challenge the ruling. Congress is also getting involved, by adding ABA therapy coverage for retirees and removing the $36,000 cap in both the Senate and House defense appropriation bills for 2013. Thirty-two states currently require health insurers to cover ABA therapy in their coverage.

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